Surgical management of salivary gland tumors. Aliu Sanni MD Long Island College Hospital 4 th April, 2013

Transcription

1 Surgical management of salivary gland tumors Aliu Sanni MD Long Island College Hospital 4 th April, 2013

2 Case presentation 51M with no significant PMHx presents with progressively enlarging right facial mass for the last 2yrs Denies pain with chewing, facial numbness or paresthesia. No history of previous facial masses, fevers, chills or weight loss.

3 Case presentation o o o General: AVSS ENT: 3cm parotid mass No evidence of regional adenopathy, facial nerve palsy, skin lesions or tenderness

4 Case presentation Labs CBC 4.3>15.5/46<276 BMP 138/4.3/103/28/13/0.9 Ca 8.6 PTT/PT/INR 25.6/10.7/1.0

5 Case presentation MRI- 2.5cm x 2.4cm x 2.6cm mass superficial/deep portion of the right parotid FNA clusters of epithelial & myoepithelial cells, consistent with pleomorphic adenoma

6 Case presentation 3/11/13- Right total parotidectomy with lymphadenectomy

7 Operative details Adhesion of the superior division of facial nerve to tumor capsule Frozen section-benign pleomorphic adenoma

8 Operative details

9 Post-operative course POD#1- D/C Home

10 Management of salivary gland tumors

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12 Anatomy Cranial border= zygoma Caudal border= SCM Posterior= mastoid process Anterior = masseter muscle

13 Histology

14 Histology

15 Facial nerve Origin: Facial nerve nucleus Exit: Stylomastoid foramen 5 Main Branches Temporal: Raises forehead Zygomatic: Eyes closure Buccal: Flairs nostrils M.Mandibular: Oral continence Cervical: Platysma

16 In parotid malignancies, the first site of lymphatic spread is the intraparotid lymph nodes, followed by level I and level II cervical nodes. Lymph nodes in the neck are grouped into levels I-V, corresponding with the submandibular and submental nodes (level I); upper, middle, and lower jugular nodes (levels II, III, IV); and posterior triangle nodes (level V). Refer to the following image.

17 Epidemiology Incidence: 1.5/100,000 individuals in US. Approximately cases/yr 700 related deaths/yr 5 th -6 th decade of life. Malignant lesions- >60 years of age Benign lesions: F>M Malignant lesions: F=M

18 Risk factors Radiation- salivary gland malignancy Smoking- Warthin s tumor Increased incidence-hiv, environmental factors and industrial exposure. EBV - lymphoepithelial carcinoma.

19 Salivary gland tumors Account for 6-8% of Head/Neck tumors Parotid glands- 80 % of salivary neoplasms Submandibular glands: % 40 to 45 % are malignant Sublingual or minor glands: 1-5% 70 to 90 % are malignant

20 Risk of malignancy- 25:50:75 rule Parotid: 20-25% Submandibular: 40 to 45 % Sublingual: 70 to 90 %

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22 Benign salivary gland tumors Pleomorphic adenoma Warthin s lymphoma Oncocytoma

23 Benign- Pleomorphic adenoma Most common benign salivary gland tumor. Mixed growth patterns- myoepithelial & epithelial cells with stromal hyperplasia Slow growing, lobular, and not well encapsulated Recurrence rate: 1-5% Carcinoma ex-pleomorphic adenoma: 2-10% of adenomas malignant degeneration in long term

24 Pleomorphic adenoma

25 Benign Warthin s tumor 2 nd most common benign tumor (5%) Higher incidence in smokers and males 6 th -7 th decades Papillary cystadenoma lymphomatosumlymphocytic & cystic epithelial proliferation 10% bilateral and multifocal parotid involvement Malignant transformation very rare

26 Benign - Oncocytoma Accounts for 1% of salivary gland tumors Most often occur in the parotid glands. Large uniform cells with distinct capsule. Composed of large oxyphilic cells - oncocytes.

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28 Malignant- Mucoepidermoid CA Most common malignant - 30% 2 nd -7 th decade: F>M Limited local invasiveness Composition- mucous, epidermoid & intermediate cells High-grade tumors behave like SCC Lymph node metastasis, 5-year survival only 5% Low-grade tumors behave like benign lesion. No nodal or distant metastasis, 5-year survival : 75-95%

29 Malignant- Adenoid cystic CA 2 nd most common; 5 th -6 th decade, M=F Well circumscribed but un-encapsulated Perineural invasion & late distant metastasis (30-50%) Lung metastases most frequent. Three types: cribrose, tubular, and solid. Solid-worst prognosis, Cribrose-best prognosis Requires aggressive initial resection. 5yr survival-35%, 10yr survival-20%.

30 Malignant- Acinic cell CA 1-3% of all salivary gland neoplasms 90% arise in the parotid Pathology- acinic & dense lymphoid cells Surgery with negative margin most important therapy 33% recurrence rate 10-15% lymph node metastasis

31 Malignant pleomorphic adenoma Carcinoma ex pleomorphic Malignant transformation - 20 years Frequent local recurrences & distant metastases Prognosis- survival based on grade Low grade- 96%, High grade-30% Carcino-sarcoma Recurrent pleomorphic adenoma or de novo Highly aggressive with distant metastasis to lung

32 Clinical Evaluation History / Physical Examination Masses-painless & slow growing Acute pain- Obstructive/Inflammatory process Features suspicious for malignancy: fixed tumor with skin involvement regional adenopathy facial nerve paralysis History of H&N skin cancer Medial displacement of oropharyngeal wall suggests deep lobe involvement

33 Imaging US/CT/MRI- Description of mass Preoperative biopsy-fnab Sensitivity: 99% Specificity: %

34 Treatment : benign tumors Superficial parotidectomy-treatment of choice. Facial nerve preservation- mandatory Deep lobe tumors- total parotidectomy with facial nerve preservation. Recurrence- postoperative radiation local control rates exceed 95%.

35 Treatment : malignant tumors

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37 T1-T2 low grade tumors Parotidectomy (superficial or total)- adequate margin and preservation of the facial nerve. First level nodal resection.

38 T1-T2 high grade tumors Total parotidectomy with neck dissection Facial nerve preservation unless direct infiltration. Nerve resection to clear margins with immediate cable graft reconstruction. Postoperative radiation.

39 T3 tumors Parotidectomy & facial nerve resection for tumor free margins. Cable graft reconstruction. Neck dissection for N+ disease. Postoperative radiation.

40 T4 tumors Radical parotidectomy with excision of the involved structures (e.g. facial nerve, mandible, mastoid tip, skin). Complex facial reconstruction Neck dissection for N+ disease Postoperative radiation therapy.

41 Complications Facial nerve Injury Hematoma Salivary fistula Frey syndrome- commonest Sensorineural hearing loss (radiation)

42 Neuropraxia

43 Frey syndrome Gustatory sweating- flushing & sweating of ipsilateral facial skin with eating Pathophysiology - aberrant parasympathetic cross re-innervation from parotid to sympathetic fibers innervating sweat glands of the skin Incidence- up to 50% post op Symptomatic treatment Botox may have a role in severe cases Skin flaps

44 Prognosis 5-year survival Stage I- 85% Stage II- 66% Stage III- 53% Stage IV- 32% 10-year survival Low-grade: 80-95% High grade: 25-50%.

45 Metastasis Parotid tumors- metastasis in 21% of cases. High grade tumors- 32%. Adenoid cystic CA- 50%. Metastasis- Lung, liver and bone. Treatment- Palliation

46 Summary Salivary gland tumors- rare and diverse group of benign and malignant lesions. Histology, staging and tumor grade are essential for treatment plan. Frozen section imperative for appropriate surgical resection.

47 References Illes RW, Brian MB. A review of the tumors of the salivary gland. Surg Gynecol Obstet. Oct 1986;163(4): CURRENT Diagnosis & Treatment in Otolaryngology Head & Neck Surgery, 3e Chapter 18. Benign Diseases of the Salivary Glands (Fidelia Yuan-Shin Butt, MD) Chapter 19. Malignant Diseases of the Salivary Glands (Adriane Concus, MD and Theresa Tran, MD)